Application For Registration As Investment Adviser Of Securities {FCN155}

FCN 2-2-155 Approved 5-24-63 DIVISION OF LICENSES AND REGISTRATION Department of Finance Government of Guam Agana, Guam APPLICATION FOR REGISTRATION AS INVESTMENT ADVISER OF SECURITIES (Filing Fee $25.00) The undersigned, an applicant for registration as an investment adviser of securities, submits the following information to the Administrator of Securities as required by S ection 45202, Uniform Securities Act of Guam 1. Name, residence address, and business address of the applic ant. 2. Name under which business is conducted. 3. Check one only. Type of Firm: ( ) Corporation ( ) Partnership ( ) Sole Proprietorship ( ) Other 4. The general plan and character of business. 5. Place and date of birth; length of residence in the Terri tory of Guam. 6. Educational history, showing name of schools with dates of attendance, and major subject. 7. Business experience during the ten years prior to this app lication, showing name and address of em- ployers, position held, nature of occupation, and dates. 8. Name and address of three references as to the character and reputation of the applicant, excluding relatives. 9. Attach a complete statement of facts relative to the quali fications, and business history of all employees. Separate sheet must be prepared for each employee. 10. If the applicant during the ten years prior to this appl ication has misappropriated or converted moneys of others for his own use, or has been accused of so doing, attach a complete statement of facts in respect thereto. 11. If applicant has been registered as an investment adviser or an agent of or broker-dealer in securities prior to this application, attach a complete statement of facts in respect thereto. 12. If applicant has been denied registration as an investment adviser or an agent or broker-dealer in securities, or has had registration as such suspended or revoke d prior to this application by any state or territorial government, attach a complete statement of facts in respect thereto. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 213. If applicant has been convicted of a violation of a crim inal statute, attach a complete statement of facts in respect thereto. 14. There shall be filed an irrevocable written consent to se rvice of process on the Administrator of Securities as provided by Section 45414 (g), Chapter 4, Title 41, Gover nment Code of Guam. 15. Current Financial Statement must be attached to this appli cation. Territory of Guam ) ) SS Agana, Guam ) being first duly sworn on oath deposes and says that ........................................................................ ....................... he is the applicant named in the foregoing information statemen t, that he has read the statement and all .... documents attached thereto, that the information contained in th e statement and documents is true to the best of his knowledge and belief. ........................................................................ ........................ (Applicant) .... Subscribed and sworn to before me this .......................day of...................................................................... 19.......... . , ........................................................................ ......................... Notary Public in and for the ... Territory of Guam. My Commission expires: ....................... . American LegalNet, Inc. www.USCourtForms.com